ICD-10 Guide

Z34.02

Encounter for supervision of normal first pregnancy, second trimester

BILLABLE STATUSYes

IMPLEMENTATION DATEOctober 1, 2015

LAST UPDATED09/12/2025

Code Description

ICD-10 Z34.02 is a billable code used to indicate a diagnosis of encounter for supervision of normal first pregnancy, second trimester.

Key Diagnostic Point:

Z34.02 is used to indicate an encounter for the supervision of a normal first pregnancy during the second trimester. This code is essential for tracking the health status of pregnant individuals and ensuring they receive appropriate preventive care and screenings. During this period, healthcare providers focus on monitoring the health of both the mother and the fetus, addressing any potential social determinants of health that may affect pregnancy outcomes, such as socioeconomic status, access to healthcare, and support systems. Preventive care may include routine blood tests, screenings for gestational diabetes, and assessments of maternal mental health. The second trimester is a critical time for education on nutrition, exercise, and prenatal vitamins, as well as discussions about labor and delivery plans. Proper documentation of these encounters is vital for accurate coding and reimbursement, as well as for tracking public health outcomes.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

Need for accurate documentation of maternal health and fetal development
Integration of social determinants of health into care plans
Potential for co-morbid conditions requiring additional coding
Variability in preventive care guidelines based on patient demographics

Audit Risk Factors

Inadequate documentation of prenatal visits
Failure to capture relevant social determinants of health
Incorrect sequencing of codes related to complications
Lack of evidence for preventive screenings performed

Specialty Focus

Medical Specialties

Primary Care

Documentation Requirements

Documentation should include details of prenatal visits, screenings performed, and any referrals made.

Common Clinical Scenarios

Routine checkups, screenings for gestational diabetes, and discussions about maternal health.

Billing Considerations

Consideration of social determinants such as access to transportation for visits and support systems at home.

Public Health

Documentation Requirements

Population-level data collection and surveillance documentation to track maternal and fetal health outcomes.

Common Clinical Scenarios

Epidemiological studies on pregnancy outcomes and preventive health initiatives.

Billing Considerations

Focus on health disparities and access to care in different populations.

Coding Guidelines

Inclusion Criteria

Use Z34.02 When

Z codes should be used when the encounter is for supervision of a normal pregnancy without complications
They should be sequenced appropriately, typically as a secondary diagnosis when a primary diagnosis exists
Payer requirements may vary, so it is essential to verify coverage for preventive services

Exclusion Criteria

Do NOT use Z34.02 When

No specific exclusions found.

Related CPT Codes

99213CPT Code

Established patient office visit, level 3

Clinical Scenario

Used for routine prenatal visits during the second trimester.

Documentation Requirements

Documentation must include history, examination, and medical decision-making.

Specialty Considerations

Primary care providers should ensure comprehensive documentation of maternal health.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of pregnancy encounters, improving data accuracy and enabling better tracking of maternal health outcomes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of pregnancy encounters, improving data accuracy and enabling better tracking of maternal health outcomes.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of pregnancy encounters, improving data accuracy and enabling better tracking of maternal health outcomes.

Resources

Clinical References

•
CDC Pregnancy Risk Assessment Monitoring System (PRAMS)

Coding & Billing References

•
CDC Pregnancy Risk Assessment Monitoring System (PRAMS)

Frequently Asked Questions

What should be documented during a Z34.02 encounter?

Documentation should include details of the visit, any screenings performed, discussions about maternal health, and considerations of social determinants of health.

ICD-10 Z34.02 is a billable code used to indicate a diagnosis of encounter for supervision of normal first pregnancy, second trimester.